Bosniak classification version 2019: a prospective comparison of CT and MRI.

OBJECTIVE: To assess the diagnostic accuracy and agreement of CT and MRI in terms of the Bosniak classification version 2019 (BCv2019). MATERIALS AND METHODS: A prospective multi-institutional study enrolled 63 patients with 67 complicated cystic renal masses (CRMs) discovered during ultrasound examination. All patients underwent CT and MRI scans and histopathology. Three radiologists independently assessed CRMs using BCv2019 and assigned Bosniak class to each CRM using CT and MRI. The final analysis included 60 histopathologically confirmed CRMs (41 were malignant and 19 were benign). RESULTS: Discordance between CT and MRI findings was noticed in 50% (30/60) CRMs when data were analyzed in terms of the Bosniak classes. Of these, 16 (53.3%) were malignant. Based on consensus reviewing, there was no difference in the sensitivity, specificity, and accuracy of the BCv2019 with MRI and BCv2019 with CT (87.8%; 95% CI = 73.8-95.9% versus 75.6%; 95% CI = 59.7-87.6%; p = 0.09, 84.2%; 95% CI = 60.4-96.6% versus 78.9%; 95% CI = 54.4-93.9%; p = 0.5, and 86.7%; 95% CI = 64.0-86.6% versus 76.7%; 95% CI = 75.4-94.1%; p = 0.1, respectively). The number and thickness of septa and the presence of enhanced nodules accounted for the majority of variations in Bosniak classes between CT and MRI. The inter-reader agreement (IRA) was substantial for determining the Bosniak class in CT and MRI (k = 0.66; 95% CI = 0.54-0.76, k = 0.62; 95% CI = 0.50-0.73, respectively). The inter-modality agreement of the BCv219 between CT and MRI was moderate (κ = 0.58). CONCLUSION: In terms of BCv2019, CT and MRI are comparable in the classification of CRMs with no significant difference in diagnostic accuracy and reliability. KEY POINTS: • There is no significant difference in the sensitivity, specificity, and accuracy of the BCv2019 with MRI and BCv2019 with CT. • The number of septa and their thickness and the presence of enhanced nodules accounted for the majority of variations in Bosniak classes between CT and MRI. • The inter-reader agreement was substantial for determining the Bosniak class in CT and MRI and the inter-modality agreement of the BCv219 between CT and MRI was moderate.

Determining the Optimal Time Interval between Vaginal Dinoprostone Administration and Diagnostic Office Hysteroscopy in Nulliparous Women: A Randomized, Double-blind Trial.

STUDY OBJECTIVE: To determine the optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nulliparous women. DESIGN: Randomized, double-blind trial. SETTING: Tertiary referral hospital. PATIENTS: A total of 180 nulliparous women undergoing diagnostic OH. INTERVENTIONS: We randomly allocated the women to long-interval or short-interval dinoprostone groups: three mg dinoprostone was administered vaginally 12 hours before OH in the long-interval group and 3 hours before OH in the short-interval group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was pain during OH measured using a 100-mm visual analog scale (0 = no pain; 100 = worst pain imaginable). The secondary outcomes were ease of hysteroscope passage, patient satisfaction score, and drug-related adverse effects. The patients in the long-interval dinoprostone group had lower pain scores during OH (p <.001). Contrarily, pain scores 30 minutes after the procedure were similar in both groups (p = .1). The patient satisfaction score was higher and clinicians found hysteroscope passage through the cervical canal easier and quicker in the long-interval dinoprostone group than in the short-interval group (p <.001, p = .003, and p <.001, respectively). Side effects were comparable in both study groups. CONCLUSION: Vaginal dinoprostone administered 12 hours before OH was more effective than that administered 3 hours before OH in reducing pain during OH in nulliparous women, with easier hysteroscope insertion, shorter procedure duration, and higher patient satisfaction score.

Evaluating efficacy of intravenous carbetocin in reducing blood loss during abdominal myomectomy: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of carbetocin versus placebo in decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Tertiary university hospital from September 2019 to February 2020. PATIENT(S): A total of 138 women with symptomatic leiomyoma who were candidates for abdominal myomectomy (n = 69 in each group). INTERVENTION(S): We randomized the study participants in a 1:1 ratio to carbetocin and placebo groups. Intravenous 100 µg carbetocin or placebo was administered slowly after induction of anesthesia. MAIN OUTCOME MEASURE(S): Intraoperative blood loss, need for blood transfusion, postoperative hemoglobin, operative time, length of hospitalization, and drug side-effects. RESULT(S): The baseline characteristics were similar among all groups. Carbetocin had significantly lower intraoperative blood loss compared with placebo (mean difference 184 mL). Hemoglobin level 24 hours after surgery was significantly lower in the placebo group than in the carbetocin group (9.1 ± 0.8 vs. 10.3 ± 0.6 g/dL). Eight women in the carbetocin group needed blood transfusion compared with 17 in placebo group. Operative time, length of hospitalization, and side-effects were similar in both groups. CONCLUSION(S): A single preoperative intravenous dose of 100 µg carbetocin is a simple, practical, and effective method of decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy, with tolerable, few, nonsignificant side-effects. CLINICAL TRIAL REGISTRATION NUMBER: NCT04083625.

The impact of sphenoid sinus pneumatization type on the protrusion and dehiscence of the adjacent neurovascular structures: A prospective MDCT imaging study.

RATIONALE AND OBJECTIVES: Sphenoid sinus (SS) pneumatization is greatly variable. Precise determination of the pattern of SS pneumatization and its relationship to the vital neurovascular structures will provide a more comprehensive understanding of the regional SS anatomy to avoid the risk of potentially serious neural and vascular injury. We aimed to study the relationships among SS pneumatization type, extent of pneumatization, and protrusion/dehiscence of adjacent neurovascular structures using the multi-detector computed tomography. MATERIALS AND METHODS: One hundred seventy healthy patients were prospectively examined by multi-detector computed tomography of the head. The type of pneumatization of the SS was determined. The protrusion/dehiscence of the internal carotid artery, optic nerve, vidian nerve, and maxillary nerve into the SS cavity was evaluated. The relationships between the SS pneumatization type and the extent of protrusion/dehiscence of the examined variables were statistically analyzed. RESULTS: We had 70 patients with no protrusion/dehiscence, 37 patients with unilateral protrusion/dehiscence, and 63 patients with bilateral protrusion/dehiscence. The presellar type was dominant (61.4%) in the group with no protrusion/dehiscence, the sellar type was dominant (56.8%) in the group with unilateral protrusion/dehiscence, and the postsellar type was dominant (55.6%) in the group with bilateral protrusion/dehiscence. The protrusion rates of the internal carotid artery, optic nerve, vidian nerve, and maxillary nerve in the postsellar type were 50.6%, 52.3%, 56.9%, and 54.1%, respectively (p< 0.001). CONCLUSION: The prevalence of protrusion/dehiscence of the neurovascular structures is significantly related to the type of SS and increases as the degree of SS pneumatization increases.

The validity and reproducibility of the thyroid imaging reporting and data system (TI-RADS) in categorization of thyroid nodules: Multicentre prospective study.

PURPOSE: To assess diagnostic validity and reproducibility of Thyroid Imaging Reporting and Data System (TI-RADS) for interpretation of thyroid nodules by thyroid ultrasonography (US). METHOD: A prospective multicentre study initially included 557 patients with clinically suspected thyroid nodules. After exclusion, a final cohort of 380 patients with 948 thyroid nodules detected by US were enrolled. Based on American College of Radiology (ACR) TI-RADS, three radiologists analysed all US examinations independently and assigned a TI-RADS category to each thyroid nodule. The final diagnosis was based on cytology which was used as reference standard for calculating diagnostic performance of TI-RADS for predicting malignant thyroid nodules. The Fleiss and weighted kappa (κ) statistics were applied to assess inter-observer agreement of morphological features and TI-RADS scoring results for thyroid nodules. Additionally, we made a simple screening among referring clinicians to assess the clinical response to application of TI-RADS. RESULTS: A total of 948 thyroid nodules were evaluated; 136 (14.3%) were malignant, and 812 (85.7%) were benign. The papillary carcinoma was the most common malignant thyroid nodules (81.6%). The best cut-off value for predicting malignant thyroid nodules was > TR3. On a lesion-based analysis, the TI-RADS had a sensitivity, specificity, and an accuracy of 98.3%, 90.9%, and 92.1%, respectively when regarding those thyroid nodules classified as > TR3 for predicting malignancy. The inter-observer agreement of the TI-RADS category was good (κ = 0.636). Ninety percent of referring clinicians accept TI-RADS. CONCLUSIONS: TI-RADS improves diagnostic performance of US for predicting malignant thyroid nodules with high validity and high reproducibility.

Gynecology Imaging Reporting and Data System (GI-RADS): diagnostic performance and inter-reviewer agreement.

OBJECTIVE: To evaluate diagnostic performance and inter-reviewer agreement (IRA) of the Gynecologic Imaging Reporting and Data System (GI-RADS) for diagnosis of adnexal masses (AMs) by pelvic ultrasound (US). PATIENTS AND METHODS: A prospective multicenter study included 308 women (mean age, 41 ± 12.5 years; range, 15-73 years) with 325 AMs detected by US. All US examinations were analyzed, and AMs were categorized into five categories according to the GI-RADS classification. We used histopathology and US follow-up as the reference standards for calculating diagnostic performance of GI-RADS for detecting malignant AMs. The Fleiss kappa (κ) tests were applied to evaluate the IRA of GI-RADS scoring results for predicting malignant AMs. RESULTS: A total of 325 AMs were evaluated: 127 (39.1%) were malignant and 198 (60.9%) were benign. Of 95 AMs categorized as GI-RADS 2 (GR2), none was malignant; of 94 AMs categorized as GR3, three were malignant; of 13 AMs categorized as GR4, six were malignant; and of 123 AMs categorized as GR5, 118 were malignant. On a lesion-based analysis, the GI-RADS had a sensitivity, a specificity, and an accuracy of 92.9%, 97.5%, and 95.7%, respectively, when regarding only those AMs classified as GR5 for predicting malignancy. Considering combined GR4 and GR5 as a predictor for malignancy, the sensitivity, specificity, and accuracy of GI-RADS were 97.6%, 93.9%, and 95.4%, respectively. The IRA of the GI-RADS category was very good (κ = 0.896). The best cutoff value for predicting malignant AMs was >GR3. CONCLUSIONS: The GI-RADS is very valuable for improving US structural reports. KEY POINTS: • There is still a lack of a standard in the assessment of AMs. • GI-RADS is very valuable for improving US structural reports of AMs. • GI-RADS criteria are easy and work at least as well as IOTA.

Brain magnetic resonance spectroscopy (MRS) as a diagnostic tool for detecting early neurological changes in children with Wilson's disease.

PURPOSE: Although brain magnetic resonance spectroscopy (MRS) imaging findings in adult Wilson disease (WD) have been explained in extensive details, a paucity of information currently exists regarding brain MRS imaging findings in pediatric WD. The purpose of this study was to clarify the role of brain MRS in detecting early metabolite abnormalities in children with WD. PATIENT AND METHODS: A case-controlled prospective study included 26 children with WD and 26 healthy controls. All children were subjected to examination on a 1.5 T MRI scanner. The spectra of N-acetyl aspartate (NAA), choline (Cho), and creatine (Cr), as well as the metabolite ratios of NAA/Cho, NAA/Cr, and Cho/Cr, were measured and compared between two groups. RESULTS: Eight patients revealed increased signal intensity in the basal ganglia at T1-weighted images. When compared with healthy controls, WD patients showed a significant decrease (p < 0.05) in NAA (63.8 ± 9.6 vs 97.6 ± 3.8), Cho (46.7 ± 8.9 vs 87.3 ± 4.7), Cr (44 ± 10.1 vs 81.9 ± 4.05), NAA/Cho (1.92 ± 1.2 vs 3.34 ± 0.55), NAA/Cr (1.29 ± 0.7 vs 2.46 ± 0.34), and Cho/Cr (0.78 ± 0.4 vs 2 ± 0.13). Patients complicated with liver cell failure showed a significant decrease in all previous parameters (p < 0.05) than patients without complications. Patients with mixed neurological and hepatic diseases showed a severe reduction in NAA, NAA/Cr, and NAA/Cho compared with patients with hepatic disease only. CONCLUSION: MRS in pediatric WD detects early neurological changes even with normal MRI.

The utility of diffusion-weighted imaging in improving the sensitivity of LI-RADS classification of small hepatic observations suspected of malignancy.

PURPOSE: We investigated the added value of diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC) in the categorization of small hepatic observation (≤ 20 mm) detected in patients with chronic liver disease in reference to LI-RADS (liver imaging reporting and data system) classification system. METHODS: We prospectively evaluated 165 patients with chronic liver disease with small hepatic observations (≤ 20 mm) which were previously categorized as LI-RADS grade 3-5 on dynamic contrast-enhanced CT (DCE-CT). All patients were submitted to a functional MRI including DCE and DWI. Using LI-RADS v2017, two radiologists independently evaluated the observations and assigned a LI-RADS category to each observation using DCE-MRI alone and combined DCE-MRI and DWI/ADC. In the combined technique, the radiologists assigned a LI-RADS category based on a modified LI-RADS criteria in which restricted diffusion on DWI was considered a major feature of HCC. We evaluated the inter-reader agreement with Kappa statistics and compared the diagnostic performance of the LI-RADS with two imaging techniques by Fisher's exact test using histopathology as the reference standard. RESULTS: Combined technique in LI-RADS yielded better sensitivities (reader 1, 97% [65/67]; reader 2, 95.5% [64/67]) for HCC diagnosis than DCE-MRI alone (reader 1, 80.6% [54/67], p = 0.005; reader 2, 83.6% [56/67], p = 0.04). The specificities were insignificantly lower in combined technique (reader 1, 88.4% [107/121]; reader 2, 77.7% [94/121]) than in DCE-MRI alone (reader 1, 90.9% [110/121], p = 0.67; reader 2, 79.3% [96/121], p = 0.88). The inter-reader agreement of the LI-RADS scores between combined technique and DCE-MRI was good (κ = 0.765). CONCLUSION: The use of DWI/ADC as an additional major criterion, improved the sensitivity of LI-RADS in the diagnosis of HCC while keeping high specificity.

Efficacy of contrast-enhanced FDG PET/CT in patients awaiting liver transplantation with rising alpha-fetoprotein after bridge therapy of hepatocellular carcinoma.

OBJECTIVE: To assess the diagnostic accuracy and illustrate positive findings of contrast-enhanced fluorine-18 fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) image in patients awaiting liver transplantation (LT) with rising alpha-fetoprotein (AFP) after bridge therapy of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This prospective study included 100 patients who were waiting for LT and who previously underwent locoregional therapy (LRT) of HCC. These patients had rising AFP levels on a routine follow-up examination awaiting LT. All patients underwent a contrast-enhanced 18F-FDG PET/CT examination. We calculated for each patient the maximum standardised uptake value (SUVmax) of the tumour and the ratio of the tumoral SUVmax to the normal-liver SUVmax. The diagnostic accuracy and positive contrast-enhanced findings of 18F-FDG PET/CT were established by histopathology and clinical and imaging follow-up as the reference standards. RESULTS: Contrast-enhanced 18F-FDG PET/CT detected tumour relapse in 78 patients (13 patients had intrahepatic lesions, 10 patients had extrahepatic metastases and 55 patients with combined lesions). The sensitivity, specificity and accuracy values of contrast-enhanced 18F-FDG PET/CT examination in the detection of HCC recurrence were 92.8%, 94.1% and 93%, respectively. A significant correlation was found between the AFP level and SUVmax ratio (r = 0.2283; p = 0.0224). The best threshold for 18F-FDG PET positivity was >1.21. CONCLUSION: Contrast-enhanced 18F-FDG PET/CT is a valuable tool for the detection of intrahepatic HCC recurrence or extrahepatic metastasis following rising AFP levels after LRT of HCC, and should be incorporated during routine workup awaiting LT. KEY POINTS: • 18F-FDG PET/CT is a valuable tool for the detection of HCC recurrence • 18 F-FDG PET/CT should be incorporated during routine workup awaiting liver transplantation • Significant correlation was found between AFP level and SUVmax ratio • The best threshold for 18 F-FDG PET positivity was >1.21 • The ideal cut-off value for AFP was >202.

Diagnostic performance of 18F-FDG PET/CT and whole-body MRI before and early after treatment of multiple myeloma: a prospective comparative study.

OBJECTIVE: To determine the diagnostic accuracy of WB-MRI and 18F-FDG PET/CT in detecting infiltration pattern, disease activity, and response to treatment in patients with multiple myeloma (MM). MATERIALS AND METHODS: Fifty-six patients with confirmed MM were included in the present study for pre-treatment evaluation. Among these individuals, 22 patients were available for the post-treatment evaluation of response to therapy. All patients were imaged with both WB-MRI and 18F-FDG PET/CT. All radiographic findings of infiltration pattern, disease activity, and response to therapy were compared. The diagnostic performance of both modalities was estimated using bone marrow aspirate and biopsy as the reference test. RESULTS: For detection of active myelomatous tissue at diagnosis, WB-MRI achieved higher sensitivity (94%) than 18F-FDG PET/CT (75%) (p = 0.0039), whereas both modalities achieved the same specificity (80%). For detection of residual myelomatous tissue after treatment, 18F-FDG PET/CT achieved higher specificity (86%) than WB-MRI (43%) (p = 0.0081), whereas both modalities achieved the same sensitivity (75%). CONCLUSION: WB-MRI is more sensitive than 18F-FDG PET/CT in the diagnosis of MM before treatment; however, 18F-FDG PET/CT is more specific than WB-MRI in detecting residual involvement in treated patients.

Autoimmune pancreatitis in an 11-year-old boy.

We report a case of histopathologically proven autoimmune pancreatitis in an 11-year-old boy. Abdominal US and MRI showed a focal swelling of the pancreatic head, the latter also showing delayed contrast enhancement. There was diffuse irregular pancreatic duct narrowing, compression of the intrapancreatic common bile duct, and mild proximal biliary dilatation on MR cholangiopancreatography. Laboratory results revealed normal serum IgG and subclass 4 with negative autoimmune antibodies, and slightly elevated carbohydrate antigen 19-9. This highlights the differentiation of autoimmune pancreatitis from pancreatic head cancer and, to a lesser extent, other forms of pancreatitis in children.